[Laparoendoscopic single site (LESS) ureteral reimplantation.]

OBJECTIVE

To present in detail our surgical technique and to show our initial experience with ureteral reimplantation using the transumbilical LESS approach to treat patients with ureteral stenosis secondary to various diseases and surgical complications.

METHODS

We performed 7 ureteral reimplantations from February 2012, using the multichannel Richard- Wolf (KeyPort) platform placed transumbilical by a small 2-2,5 cm transversal incision. We always use a 3.5 mm minilaparoscopy accessory trocar in the right iliac fossa, that is crucial to perform the laparoscopic suturing safely for the patient and in an optimal time. The etiology of ureteral lesions was: 1 endometriosis, 1 symptomatic ureterocele not responding to endoscopic treatment, 1 ureteral lesion after ureteroscopy for lithiasis, 1 ureteral lesion after radical prostatectomy and 3 gynecologic iatrogenic lesions (1 laparoscopically assisted vaginal hysterectomy, 2 radical hysterectomies with double anexectomy for cervix carcinoma). 5 ureteral reimplantations were left and 2 right sides. Before surgery, 5 patients had nephrostomy tubes inserted and the patient with endometriosis had a double J catheter. The patient with ureterocele did not require urinary diversion before the operation and endoscopic intraoperative catheterization was not feasible.

RESULTS

We present the operative and postoperative results of the patients undergoing surgery. They had a mean age of 49.3 [28-78] years. Mean intraoperative estimated blood loss was 132.1 [100-250] ml, with no transfusions required. Mean operative time was 127.4 [120-210] minutes, with no conversions to laparoscopic or open surgery required. Mean hospital stay was 2.1 [2-3] days and all patients had drainage removed at 48 hours. There were minor Clavien-Dindo complications in one patient presenting urinary tract infection 10 days after the operation. All patients had double J catheters that were removed with a mean of 34.3 [30-45] days. Mean time for bladder catheter removal was 7.8 [7-10] días. With a mean follow up of 32.6 [14-54] months no ureteral stenosis recurrence has been observed.

CONCLUSIONS

LESS ureteral reimplantation, in our initial experience, shows a low complication rate, similar to current laparoscopic series, offering less postoperative pain and abdominal wall aggression with great cosmetic results that are perceived by patients very positively, in addition to rapid recovery and return to normal daily life.

Posterior wall left ventricular aneurysm repair

Posterior wall aneurysms are a relatively rare form of left ventricular aneurysm that can sometimes involve the mitral valve. This tutorial illustrates the technical aspects of posterior wall left ventricular aneurysm repair.

Does aortic valve repair in valve-sparing aortic root reconstruction compromise the longevity of the procedure?

OBJECTIVES:

The effect of performing aortic valve repair in combination with valve-sparing operation on the length of time for which patients are free from reoperation is unclear. The objective of this study was to determine if the performance of aortic valve repair during valve-sparing operation modified the freedom from reoperation time.

METHODS:

From January 2003 to July 2014, 78 patients with a mean age of 49±15 years underwent valve-sparing operation. Sixty-eight percent of these patients were male. Twenty-two (28%) aortic valve repair procedures were performed in this patient population. In the aortic valve repair + valve-sparing operation group, 77.3% of patients had moderate/severe aortic insufficiency, while in the valve-sparing operation group, 58.6% of patients had moderate/severe aortic insufficiency (ns = not significant). Additionally, 13.6% of patients in the aortic valve repair + valve-sparing operation group had functional class III/IV, while 14.2% of patients in the valve-sparing operation group had functional class III/IV (ns).

RESULTS:

The in-hospital and late mortality rates, for the aortic valve repair + valve-sparing operation and valve-sparing operation groups were similar, as they were 4.5% and 3.6%; and 0% and 1.8%, respectively. In the aortic valve repair + valve-sparing operation group, 0% of patients presented moderate/severe aortic insufficiency during late follow-up, while in the valve-sparing operation group, 14.2% of patients presented with moderate/severe aortic insufficiency during this period (ns). In the aortic valve repair + valve-sparing operation group, 5.3% of patients presented with functional class III/IV, while in the valve-sparing operation group, 4.2% of patients presented with functional class III/IV (ns). In the aortic valve repair + valve-sparing operation group, 0% of patients required reoperation, while in the valve-sparing operation group, 3.6% of patients required reoperation over a mean follow-up period of 1621±1156 days (75 patients).

CONCLUSION:

Valve-sparing operation is a safe and long-lasting procedure and performance of aortic valve repair when necessary does not increase risk of reoperation on the aortic valve.

Extruded talus treated with reimplantation and primary tibiotalocalcaneal arthrodesis

Extruded talus is a rare serious result from a high-energy injury to a supinated and plantar flexed foot. Treatment remains controversial with a lack of congruent evidence for talar reimplantation. A 34-year-old woman was involved in a road traffic accident at 40 mph. Imaging revealed a left talus extruded anterolaterally with a talar neck fracture. Additional injuries included right acetabular fracture, transverse process fractures and rib fractures, which were treated conservatively. The talus was reimplanted and the talar neck fixed with a cortical screw. A hindfoot nail was used to fuse the calcaneus, talus and tibia. Follow-up at two years showed solid tibiotalocalcaneal fusion, with no evidence of avascular development, and the patient was fully weight bearing without pain. We believe this is the first published case of successful primary tibiotalocalcaneal fusion for extruded talus injuries.

Reimplantation of a Large Extruded Segment of Bone in an Open Fracture

Replacing an extruded segment of bone in an open fracture imposes a challenging decision concerning the best and safest patient management. There are numerous advantages to restoring the patient's own extruded bone segment to its original location, particularly when the bone segment is of structural importance. However, reimplantation of contaminated and avascular extruded bone segments can potentially result in serious infection or nonunion. There is no conclusive evidence regarding the best decontamination protocol for the safest use of the recovered bone segment as an autologous graft. Among the different chemical sterilization solutions 10% povidone-iodine and chlorhexidine gluconate solutions are the author's most preferred solutions. Regarding cellular toxicity, 10% povidone-iodine has been found to be the most favorable among the readily available solutions.

[Autotransplantation of the internal carotid artery in patients with high localization of an atherosclerotic plaque]

Acute and chronic cerebral circulatory impairment is a very commonly encountered type of neurological diseases, annually affecting more than six million people worldwide. The absolute majority of all cases are associated with atherosclerosis of cerebral arteries. Surgical intervention in a stenotic lesion of the internal carotid artery (ICA) is a method of preventive treatment with confirmed efficacy. Eversion carotid endarterectomy (ECEA) is currently the most commonly used 'open' operation for this cohort of patients. It is connected with relative technical simplicity of the operative procedure, no foreign material in the wound, low risk of haemodynamic disorders in the zone of reconstruction owing to no considerable alteration in the ICA diameter, as well as favourable remote results. A disadvantage of ECEA is lack of visual control above the distal portion of the ICA and, as a consequence, limited application of the technique in cases of a highly located atherosclerotic plaque (by more than 2 cm above the bifurcation). Specialists of the Federal Centre of Cardiovascular Surgery in the city of Penza worked out a modification of the operative technique making it possible to widen the indications for using ECEA. Its essence consists in total resection of the stenosed portion of the ICA, performing eversion endarterectomy outside the wound, followed by reimplantation thereof with the help of two 'end-to-end' anastomoses, as during prosthetic repair. This technique was called autotransplantation of the ICA. Advantages of this technique are considered to include precision of removing the plaque and intimal ruptured fragments, which is easier and more convenient to achieve outside the wound; reliable fixation of the intima and non-stenosing residuals of the plaque by a distal anastomosis, as well as a possibility of using this technique in cases of high location of the plaque. The purpose of this study was to compare the immediate results_outcomes of ECEA and autotransplantation of the ICA in two groups comprising 108 and 72 patients, respectively. The measures assessed included the mean time of ICA cross-clamping during surgery, frequency of the development of perioperative strokes, haemorrhage, lesions of craniocerebral nerves, wound complications.

Lessons learned over a decade of pediatric robotic ureteral reimplantation

The da Vinci robotic system has improved surgeon dexterity, ergonomics, and visualization to allow for a minimally invasive option for complex reconstructive procedures in children. Over the past decade, robot-assisted laparoscopic ureteral reimplantation (RALUR) has become a viable minimally invasive surgical option for pediatric vesicoureteral reflux (VUR). However, higher-than-expected complication rates and suboptimal reflux resolution rates at some centers have also been reported. The heterogeneity of surgical outcomes may arise from the inherent and underestimated complexity of the RALUR procedure that may justify its reclassification as a complex reconstructive procedure and especially for robotic surgeons early in their learning curve. Currently, no consensus exists on the role of RALUR for the surgical management of VUR. High success rates and low major complication rates are the expected norm for the current gold standard surgical option of open ureteral reimplantation. Similar to how robot-assisted laparoscopic surgery has gradually replaced open surgery as the most utilized option for prostatectomy in prostate cancer patients, RALUR may become a higher utilized surgical option in children with VUR if the adoption of standardized surgical techniques that have been associated with optimal outcomes can be adopted during the second decade of RALUR. A future standard of RALUR for children with VUR whose parents seek a minimally invasive surgical option can arise if widespread achievement of high success rates and low major complication rates can be obtained, similar to the replacement of open surgery with robot-assisted laparoscopic radical prostectomy as the new strandard for men with prostate cancer.

Wire in the hole: a case series of eroded intrapubic wire sutures causing genitourinary complications in the bladder exstrophy complex

Bladder exstrophy and cloacal exstrophy are rare congenital defects of the genitourinary tract that require complex surgical reconstruction. Malrotation of the bony pelvis causes a characteristic diastasis of the pubic symphysis, which is surgically reduced at the time of initial bladder closure. For a successful primary closure without tension such that the bladder can be placed deep within the pelvis, pelvic osteotomy is often used. However, alternative techniques have been utilized to bring the pubic rami into apposition. The authors present four bladder/cloacal exstrophy patients in which an intrapubic wire was used for pubic apposition, resulting in significant genitourinary complications.

Cooling Composite Graft for Distal Finger Amputation: A Reliable Alternative to Microsurgery Implantation

BACKGROUND

Finger amputations are the most common injuries to the upper limb. There are many options in the management of fingertip or finger amputations. We report our experience using cooling composite graft (Hirase technique) for distal finger amputation, as alternative to microsurgery implantation.

PATIENTS AND METHODS

We collected a case series of eight patients and report on the clinical outcomes after a 10-month follow-up period.

RESULTS

The amputated part survived almost completely in six patients; in these cases, the fingertip amputations were classified, according to the Allen classification, as level I in two cases, level II in three cases and level III in one case.

CONCLUSION

Re-implantation of an amputated finger with the Hirase technique is possible and can provide good distal soft-tissue coverage and recovery of sensory and motor functions. We believe that re-attachment of the amputated portion as a composite graft represents an important alternative to microsurgery.

Aortic Arch Aneurysm and Patent Left Internal Mammary Artery: Technique of Transposition of Supra-aortic Vessels and Embolization of the Subclavian Artery

Endovascular treatment of aortic arch aneurysms poses unique problems because of vascularization of the carotid arteries.

Transposition of supra-aortic vessels is becoming an established and accepted strategy for expanding the applicability of stent graft repair. left subclavian artery (LSA) is not usually transposed because its overstenting does not produce relevant complications. Nevertheless, some selected cases need high-pressure revascularization of the LSA, such as in the presence of a patent left internal mammary artery. We present a technique of revascularization of supra-aortic vessels and “balloon protected” embolization of the origin of the LSA.

Role of Temporary Arterial Shunt in the Reimplantation of a Traumatic Above-Elbow Amputation

Although the feasibility of reimplantation has increased greatly with the development of new surgical techniques, long-term functional prognosis is unpredictable. Injury to a major nerve is an important factor in long-term outcome, and prolonged ischemia time also has a negative effect. We present a 26-year-old woman whose right arm was sectioned above the elbow in an accident. The limb presented a complete section, with soft tissue loss of the humeral artery and vein, basilic vein, and cephalic vein. Median and radial nerve tissue was missing, and a supracondylar fracture with substantial loss of the humerus was also observed. During reimplantation surgery, a temporary arterial shunt reduced ischemia time. A venous and arterial bypass was performed, and the 12-month results were good.

Controlled continuous systemic heparinization increases success rate of artery-only anastomosis replantation in single distal digit amputation: A retrospective cohort study

Replantation is a prime indication for distal digital amputation, as it helps restore hand aesthetics and functions; however, venous anastomosis is often not feasible. Previous studies used systemic anticoagulation in distal digital artery only anastomosis replantation surgery to improve replantation success rate, however, which yielded limited level of clinical evidence. This study aimed to compare controlled continuous heparinization (CCH) and intermittent bolus heparinization (IBH) for surgical outcome and clinical variables after single distal digital artery only anastomosis replantation surgery.A single-institution, retrospective cohort study was performed. Out of 324 patients who underwent digital replantation surgery, we focused the study for the Zone I and II single distal digital amputation patients excluding confounding factors. Sixty-one patients were included in this study and underwent artery-only anastomosis replantation surgery with postoperative CCH (34 patients) or IBH (27 patients) protocols. The CCH group targeted activated partial thromboplastin time (aPTT) at 51 to 70 seconds, monitoring aPTT levels every eight hours and administering 100 mg of aspirin per day. The IBH group received 300 mg of aspirin per day and underwent IBH (12,500 U). Both groups received intravenous prostaglandin E1 drips (10 μg). To verify the factors affecting the success rate of the heparin protocol, patient factors, clinical factors, and operative factors were extracted from the medical records. Statistical analysis with inverse probability of treatment weights propensity score methods compared treatment outcomes and clinical variables.The CCH group's replantation success rate was higher (91.17% vs 59.25%), and the transfusion rate was increased (P = 0.032). However, the significant decrease in hemoglobin levels (>15%) did not differ between the groups (P = 0.108). Multivariable logistic regression analysis with potent univariate variables (P < .10) revealed that CCH was a statistically significant variable in replantation success rate (P = 0.004). Neither the major bleeding complications nor the significant decrease in patients' platelet levels were observed in both groups.Our study suggests that CCH after artery-only anastomosis replantation surgery in Zone I and II distal digital replantation is a safe method to improve the replantation success rate and may provide a guideline for use of the anticoagulation method following artery-only anastomosis distal digital replantation surgery.

Ureteric re-implant for the strictured renal allograft: How I do it

Ureteric stricture is the most common urologic complication following renal transplantation. Initial treatment should consist of endoscopic management, however patients that fail endoscopic management or strictures that are not amendable to endoscopic management are appropriate candidates for open surgical repair. In this manuscript we describe the steps and surgical technique we use to manage complicated ureteric strictures refractory to endoscopic management at our center. Ureteric re-implant with the use of a Boari flap is a safe, effective and definitive option for repair of ureteric strictures following renal transplantation. This approach provides excellent long term outcomes in terms of renal function preservation and negligible recurrence rates.

[Treatment by bloodletting in the past and present]

INTRODUCTION

Therapeutic bloodletting has been practiced at least 3000 years as one of the most frequent methods of treatment in general, whose value was not questioned until the 19th century, when it was gradually abandoned in Western medicine, while it is still practiced in Arabic and traditional Chinese medicine.

CONTENT

In modern medicine bloodletting is practiced for very few indications. Its concept was modeled on the process of menstrual bleeding, for which it was believed to"purge women of bad humours. "Thus, bloodletting was based more on the belief that it helps in the reestablishment of proper balance of body "humours" than on the opinion that it serves to remove excessive amount of blood as well as to remove toxic "pneumas" that accumulate in human body. It was indicated for almost all known diseases, even in the presence of severe anemia. Bloodletting was carried out by scarification with cupping, by phlebotomies (venesections), rarely by arteriotomies, using specific instruments called lancets, as well as leeches. In different periods of history bloodletting was practiced by priests, doctors, barbers, and even by amateurs. In most cases, between one half of liter and two liters of blood used to be removed. Bloodletting was harmful to vast majority of patients and in some of them it is believed that it was either fatal or that it strongly contributed to such outcome. In the 20th century in the "Western"medicine bloodletting was still practiced in the treatment of hypertension and in severe cardiac insufficiency and pulmonary edema, but these indications were later abandoned.

CONCLUSION

Bloodletting is still indicated for a few indications such as polycythemia, haemochromatosis, and porphyria cutanea tarda, while leeches are still used in plastic surgery, replantation and other reconstructive surgery, and very rarely for other specific indications.

[DECOMPRESSION AND DIVERTING EFFECTS OF VASCULAR ANASTOMOSIS BASED ON DIGITAL ARTERIAL ARCH BRANCH IN REPLANTATION OF FREE FINGER-PULP]

OBJECTIVE

To investigate the decompression and diverting effects of vascular anastomosis based on the digital arterial arch branch in replantation of free finger-pulp in distal phalanges.

METHODS

A retrospective analysis was performed on the clinical data of 12 patients (12 fingers) who underwent free finger-pulp replantation with anastomosis of proper palmar digital artery and the palmar digital artery arch branch in the distal end between December 2004 and March 2015. Of 12 cases, 9 were male and 3 were female, aged 15-39 years with an average of 32 years. The causes of injury included cutting injury in 4 cases, crush injury in 7 cases, and avulsion injury in 1 case. The thumb was involved in 2 cases, index finger in 4 cases, ring finger in 3 cases, middle finger in 1 case, and little finger in 2 cases. The free finger pulp ranged from 1.8 cm x 1.5 cm to 2.8 cmx2.0 cm. The time from injury to operation ranged from 1.5 to 11.0 hours, with an average of 5.7 hours. No arterial arch or proper palmar digital arteriae anastomosis was excluded.

RESULTS

Free finger-pulp survived in 11 cases after operation; venous crisis occurred in 1 case at 2 days after operation, and was cured after symptomatic treatment. Nine cases were followed up 6-18 months with an average of 10 months. The finger-pulp had good appearance, clear fingerprint, and soft texture. The two-point discrimination was 3.1-6.0 mm, with an average of 4.6 mm at 6 months after operation. The function of finger flexion and extension was normal. And according to upper extremity functional evaluation standard by hand surgery branch of Chinese Medical Association, the results were excellent in 7 cases, and good in 2 cases.

CONCLUSION

In the replantation of amputated pulp with insufficiency of venous blood outflow, the anastomosis of digital arterial arch branch in the distal end can decompress and shunt arterial blood, adjust blood inflow and outflow, and solve the problems of insufficient quantity of the vein and venous reflux disturbance.

[Stagewise treatment of a giant false paraanastomotic aneurysm of the abdominal aorta]

The article deals with a case report concerning successful stagewise treatment of a patient presenting with a giant false abdominal aortic paraanastomotic aneurysm having developed 2 months after an operation of linear prosthetic repair for a juxtarenal aneurysm with reimplantation of the left renal artery. The secondary operation was carried out 3 months after aortic reconstruction. The first stage consisted in performing endovascular prosthetic repair of the abdominal aortic paraanastomotic pseudoaneurysm by means of a bifurcated stent graft Endurant II (Medtronic), with the second stage being laparotomy with the removal of the retroperitoneal haematoma. The postoperative period turned out uneventful. The patient was discharged from hospital on the 8th day after the second operation. The patient was examined 2 months later, presenting no complaints and returning to his previous work. According to the findings of the check-up duplex scanning, the graft was patient, with no evidence of a paraanastomotic aneurysm. This is followed by discussion of the problems regarding the use of surgical and endovascular technologies in treatment of paraanastomotic aortic aneurysms.

[Application of Halo-vest head ring in replantation of total scalp avulsion]

OBJECTIVE

To investigate the clinical effect of Halo-vest head ring in the treatment of replantation of total scalp avulsion.

METHODS

We treated 11 cases of total scalp avulsion with the anastomosis of arteriovenous vessels and Halo-vest head ring from December 2006 to February 2015.

RESULTS

One patient's replanted scalp got necrosis because of serious contusion which was healed without hair growth after free skin graft and dressing. All the scalp flaps in the other 10 patients survived. After 3-96 months follow-up, the wound completely healed, the scalp and hair grew well with satisfactory appearance.

CONCLUSIONS

The use of Halo-vest head ring for replantation of total scalp avulsion can effectively improve the survival rate and survival area.

[MODIFIED Politano-Leadbetter REIMPLANTATION FOR TREATMENT OF CONGENITAL MALFORMATION OF VESICOURETERAL JUNCTION IN CHILDREN]

Corresponding author: HUANG Lugang, E-mail: lugang992001@aliyun.com

OBJECTIVE

To explore the effectiveness of modified Politano-Leadbetter reimplantation for the treatment of congenital malformation of the vesicoureteral junction in children.

METHODS

A retrospective analysis was made on the clinical data of 53 patients with congenital malformation of the vesicoureteral junction treated with modified Politano-Leadbetter reimplantation between June 2000 and October 2014. Of 53 cases, there were 24 boys and 29 girls, aged from 8 months to 7 years (mean, 2.1 years); 23 had congenital vesicoureteral junction obstruction (14 left, 5 right, and 4 bilateral), and 30 had vesicoureteral reflux (12 unilateral, 18 bilateral), which were verified by voiding cystourethrography. The disease duration was from 1 month to 1 year (mean, 5 months).

RESULTS

All of the patients underwent modified Politano-Leadbetter reimplantation successfully. The mean operation time was 74 minutes (range, 65-85 minutes) for unilateral cases and 105 minutes (range, 98-130 minutes) for bilateral cases. There was no dysuria, infection of incision, or incision dehiscence after urinary catheter removal. The follow-up time was 6 months to 14 years (median, 28 months); all patients were free from complications of fistula, vesicoureteral reflux, vesicoureteral junction obstruction, or hypertension. The new ureteral orifices had good appearance at 1 month after operation. Urologic ultrasound showed that hydronephrosis relieved at 3 months after operation. Urinary tract infection rate was 13.2% (7/53) during 6 months after operation, which was cured by antibiotics. Voiding cystourethrography showed no vesicoureteral reflux in 32 cases at 6 months after operation.

CONCLUSION

The modified Politano-Leadbetter reimplantation simplifies he operation course, which has the longitudinal ureter after operation and is similar to physiological state. It is a safe and effective option for congenital malformation of vesicoureteral junction in children with few complications, especially for patients with unilateral megaloureter.

[Replantation of amputated ear with anastomosis of vessel]

OBJECTIVE

To investigate the application of microsurgical technique in the replantation of amputated ear.

METHODS

7 cases of amputated ears were analyzed from June 2009 to April 2015 in our department. We used microsurgical technique to anastomose about five vessels and nerves. The blood supply of auricle was restored within three to six hours. All subjects underwent treatments including anti-freezing, anti-spasm and anti-infection treatment after the emergency surgery.

RESULTS

7 amputated ears were all survived after replantation. The patients were followed up for one month to six months ( average for 28 months). The appearances of survived ears body were fully recovered without any significant atrophy or pigmentation. The sensory function of ears recovered to normal after 1 year.

CONCLUSIONS

The application of microsurgical technique in the replantation of amputated ear can expect the high success rate of ear replantation. However, skilled and high-quality anastomosis technique of small vascular are required.

Successful reimplantation of extruded long bone segments in open fractures of lower limb--a report of 3 cases

Extruded bone segments are rare complication of high energy open fractures. Routinely these fractures are treated by debridement followed by bone loss management in the form of either bone transport or free fibula transfer. There are very few reports in the literature about reimplantation of extruded segments of bone and there are no clear guidelines regarding timing of reimplantation, bone stabilisation and sterilisation techniques. Reimplantation of extruded bone is a risky procedure due to high chances of infection which determines the final outcome and can result in secondary amputations. We present two cases of successful reimplantation of extruded diaphyseal segment of femur and one case of reimplantation of extruded segment of tibia.

Extracorporeal Irradiation in Malignant Bone Tumors

Extracorporeal irradiation (ECI) is relatively a rare method used in the management of malignant bone tumors (MBT). It consists of en block removal of the tumor bearing bone segment, removal of the tumor from the bone, irradiation and re implantation back in the body.

Digit Replantation The First 50 Years

Since the first successful digit replantation by Japanese surgeons Komatsu and Tamai, the past half century has seen the field of digit replantation in the USA experience exponential growth followed by a steady decline in volume of cases and percentage of successful viable digits. The initial enthusiasm and technical progress of digital replantation has been tempered by mediocre functional outcomes, rising healthcare costs, and limited healthcare resources. The history and approach to digit replantation is reviewed and highlights the likely push toward the development of regional replant centers staffed by highly skilled teams to improve the functional outcomes following these complex procedures. More than 50 years have passed since the first successful digit replantation by Komatsu and Tamai who replanted a sharply amputated thumb in a 28-year-old male at the metacarpal-phalangeal joint level in a 4.5 hour procedure. Two arteries and 2 veins were anastomosed using 8-0 monofilament nylon and 7-0 braided silk suture. The patient remained in the hospital for 40 days and did not return to work for 4 months. News of this triumph of microvascular skill was heralded throughout the world as the first successful replantation of a completely amputated digit. Over the past half century, the field of digit replantation in the USA experienced exponential growth followed by a steady decline in volume of cases and percentage of successful viable digits. The initial enthusiasm and technical progress of digital replantation has been tempered by mediocre functional outcomes, rising healthcare costs, and limited healthcare resources. In the next 50 years, it is possible that the majority of digit replantation procedures in the USA may be performed in tertiary centers or regional replant centers by highly skilled teams.